Executive summary

Pharmaceutical manufacturers spend vast sums of money on promotion, including sales representatives, samples, advertisements in broadcast and print media, and sponsorship of educational events and conferences. In the USA alone, almost US$21 billion was spent on promotion in 2002. In developing countries sales representatives are frequently the only source of drug information.

This report is part of a project on drug promotion being carried out by WHO and HAI Europe. This stage of the project involved collecting and analysing existing information on promotion. A database (http://www.drugpromo.info) including over 2700 journal articles, books and other material has been developed. Research studies from the database were analysed and these form the basis of this report.

What attitudes do professional and lay people have to promotion?

Research suggests that doctors' attitudes to promotion vary, and do not necessarily match their behaviour. Their opinions differ on the value of sales representatives, on whether they should be banned during medical training, and on whether doctors are adequately trained to interact with them. Most doctors think information from pharmaceutical companies is biased, but many think it is useful. Health professionals find small gifts from drug companies acceptable. Doctors who report relying on promotion tend to be older, and more likely to be general practitioners. Opinions about direct-to-consumer advertising of prescription medicines (DTCA) are mixed. Most companies, the advertising industry and the media favour it, while doctors generally oppose it. Consumers and patients are divided on the issue.

Studies on people's attitudes to promotion rely too much on quantitative surveys, on the use of convenient, accessible samples, and on describing the prevalence of attitudes rather than relationships between attitudes and other characteristics. Qualitative studies are needed in this area.

What impact does pharmaceutical promotion have on attitudes and knowledge?

Doctors themselves report that they often use promotion as a source of information about new drugs. Doctors in private practice, or who graduated long ago report the highest use of promotion as a source of drug information. Promotion influences attitudes more than doctors realise.

There is no research in the database on the impact of promotion on the attitudes of other groups, such as consumers, pharmacists, nurses or drug-store staff, all of whom are important decision-makers about medicines. Such research would be useful for developing interventions for these groups.

What impact does pharmaceutical promotion have on behaviour?

This is the most important and most difficult area to research. People may not be aware how much promotion influences them, and/or they may be unwilling to report this.

Research clearly shows that doctors who report relying more on promotion tend to prescribe less appropriately, prescribe more often and adopt new drugs more quickly. Samples appear to influence prescribing, but more research is needed on this issue. Studies which look at the impact of promotion on overall sales usually show increased sales after promotional activities. Pharmaceutical funding for doctors, such as research funding, increases request for medicines made by these companies to be added to hospital formularies. DTCA is associated with increased requests from patients for advertised medicines. Sponsorship may affect the content of continuing medical education.

The pharmaceutical industry has become a much more significant source of funding for academic research. Industry funding tends to be associated with influence over the choice of topic, secrecy, delayed publication and conflicts of interest. Pharmaceutical company funded research is more likely to show results favourable to the product being studied than research funded from other sources.

More research is needed on the public health consequences of drug promotion. For example, this might explore causal relationships between promotion and prescribing of drugs which have little or no place in rational prescribing, or which have serious adverse consequences when over-prescribed, such as antibiotics. More research is needed on the effect of promotion in developing countries.

What interventions have been tried to counter promotional activities, and with what results?

This report does not describe the whole range of interventions that have been used, only those which have been the subject of evaluative research.

Many studies show that printed advertisements do not meet regulations and guidelines in force in various countries. Neither self-regulatory systems nor review by journal editors provide effective control on drug advertising. Studies of promotion by drug company representatives suggest that the guidelines and regulations that should control them are ineffective. The only reported regulatory system for post-marketing surveillance that has been studied has not been successful. Many organizations lack adequate policies for dealing with conflicts of interest. Guidelines for regulating contacts between companies and medical trainees vary greatly between institutions. There is conflicting evidence about whether these affect the attitudes of trainee doctors, and if so whether these effects persist over time. Education about promotion appears to change attitudes and can improve skills. Its impact on prescribing has not yet been tested. Publication of descriptions of deceptive promotion can lead manufacturers to improve their promotional practices.

Interventions need to be designed using the current evidence base about drug promotion, and these need to be evaluated and published. Research comparing the effect of different regulatory frameworks is urgently needed.

Conclusions

There is a wide range of evidence on different topics, using a range of different designs, suggesting that promotion affects attitudes and behaviour. However there are gaps in the evidence, and more high-quality studies are needed to establish causal relationships between promotion and attitudes and behaviour of doctors and others, to provide more nuanced information about people's attitudes to promotion, and to investigate the impact of interventions to regulate or counter the effect of promotion.